Pediatric Coding Alert

Question: An asthmatic patient came in for a sick visit, in which I diagnosed an upper respiratory infection. Since she was behind on her vaccinations, I also had staff give her three missed vaccines. I cannot enter all the diagnoses in the electronic health record. This happens quite often. What should I do about this ICD-9 limitation? Texas Subscriber Answer: ICD-9-CM guidelines do not restrict how many diagnoses you can report per encounter. The CMS- 1500 form lists only four places for diagnosis code entries. Since the above case calls for reporting five diagnoses, you'll have to split the final vaccine product, administration, and diagnosis on a secondary form. Keeping the related product and administration together will help avoid a denial for unconnected vaccine product and administration codes. Enter diagnosis 1 (URI, for instance, 465.9, Acute upper respiratory infections of multiple or unspecified sites; unspecified site) and 2 (asthma, such [...]